This article, written by Tanya Foubert, was originally published in the summer 2014 edition of The HIROC Connection. The HIROC Connection can be viewed online at www.hiroc.com.

Radical changes in healthcare are nothing new for Saskatchewan. Once again they’re leading the way, using Lean Management to implement a culture of continuous improvement.

Close to five years ago, Saskatchewan residents told Patient First Review Commissioner Tony Dagnone the status quo was no longer working when it came to health care quality. Healthcare leaders saw it as a call to action. “All too often, healthcare reviews are commissioned and then put on the shelf and forgotten,” says Saskatoon Health Region president and CEO Maura Davies. “Our review was the catalyst for system-wide change.”

Creating the conditions for making deep and dramatic system changes across an entire province is no small task. But listening to three people who put themselves in the middle of those changes, you realize that for them and an army of supporters, there was no alternative. Maura, along with Suann Laurent, Sunrise Regional Health Authority President and CEO, and Bonnie Brossart, Saskatchewan Health Quality Council CEO, shared lessons learned from the Saskatchewan Lean Management journey at the recent CCHL (Canadian Council of Healthcare Leadership) Conference in Banff.

“Why did we start down this path?” asked Ms. Davies. “There were lots of reasons, but one in particular was because our system simply was not working the way our population or our provider community wanted it to. We were painfully conscious that we were, in some cases, providing unsafe care.”

Pick one Approach

The journey began with visits to other parts of Canada, the United States, England and Sweden to observe other healthcare systems in action. Many of these health system leaders also came to Saskatchewan to share their story. It came as no surprise to learn that success was linked to strong leadership and supporting those who are making the changes.

“We also heard that you need to commit to a very disciplined approach to quality improvement,” she says. “Pick one approach and be consistent and disciplined in your application.”

Widely known for its applicability to manufacturing, healthcare leaders decided to adopt Lean as their philosophy and management system to make care safer and better for Saskatchewan residents. Saskatchewan’s Lean Management System has three components:

One

A strategic planning process where everyone in the system thinks and acts like one – also known as Hoshin Kanri (a Japanese phrase, Hoshin Kanri is the system by which goals are determined, plans to achieve those goals are established, and measures created to ensure progress towards those goals).

Two

Developing infrastructure to support and coordinate continuous improvement across work units and settings.

Three

Building the capability among leaders and the entire healthcare workforce to do daily continuous improvement.

First, they zeroed in on fixing the waste in the system. “Whether it was through wait times or warehouses over-stocked with supplies,” said Davies, “both patients and providers were experiencing this waste.” In just three years, that approach has dramatically altered surgery wait times – from a goal of waiting no longer than 18 months for the first year, it’s dropped to 12 months, six months and now three months.

“We have hit that mark at 89 per cent for our province and we plan on hitting 100 per cent this year,” says Suann Laurent. “That is laudable and actually nothing short of remarkable for our patients.” If there is anything they’ve learned, it’s that thinking and acting like one doesn’t just happen. “Everyone knows about herding cats, well, coming up with a plan that everybody agrees with and focuses on is really quite amazing,” says Davies.

“Our system simply was not working the way our population or our provider community wanted it to. We were painfully conscious that we were, in some cases, providing unsafe care.”

Strategy Deployment at the Point Of Care

This is strategy deployment on a scale most provinces and territories would have a hard time believing, much less executing. But, don’t forget this is Saskatchewan, where radical healthcare shifts are expected. “What we’re doing in Saskatchewan is actually strategy deployment to the point of care – meaning that everyone, including the ministry, the CEOs of all the regions, our partners, patients, families and staff are making these improvements together,” says Laurent.

Being aware of the warts and not running away from them has given the project honesty and momentum. “I think one of the most powerful things we have done is really involving the point of care staff,” says Laurent. With 40,000 healthcare employees, that means staff feedback is included in strategies to improve the system.

“We went from thinking that mistakes are inevitable and they just happen, to thinking zero defects are possible and that is the only acceptable goal in our health system.”

There are over 600 leaders in the system currently working towards Lean certification; today 83 have reached that goal. The target is 880 certified by 2017. Basic training in Lean management is mandatory and over 16,000 of the

40,000 healthcare workers have received that training. To date there’s been over 300 improvement events across the province (including Rapid Process Improvement Workshops, 5S campaigns, Kanban seminars, etc). Health care staff and physicians aren’t the only participants in these improvement events – it’s mandatory that for every RPIW, a patient or family advisor must be on the team!

Another area they’ve focused on has been around building healthcare infrastructure. As part of the management strategy, every capital project goes through a 3P – or production preparation process. Since 2011, the cost avoidance in terms of building and operational costs for new facilities has been in the millions.

3Ps are not restricted to infrastructure – they’ve proven to be an effective tool for dealing with safety issues. “Each of the health regions had their own process for identifying safety issues,” said Bonnie Brossart. “For example, the Saskatoon Health Region had seven different ways to report a safety issue.” Staff was frustrated by inconsistent reporting that often went into a “black box” or “void”. A 3P for safety issues was put in place in December and a province-wide safety alert/Stop the Line System is now being tested at St. Paul’s Hospital in Saskatoon. The ambition is to have one consistent provincial system in place by 2017.

Mistake-Proofing Takes Hold

A key step on the learning journey, says Brossart, was doing a radical rethink on their approach to defects. “We went from thinking that mistakes are inevitable and they just happen, to thinking zero defects are possible and that is the only acceptable goal in our heath system.” It’s called mistake-proofing and of the 88 mistake-proofing teams, over half have reached their goal. Brossart says the lessons learned are always applied system-wide. “Without standards there can be no improvement,” she said. The Health Quality Council is the provincial agency with the mandate to report on quality. Every improvement event undertaken throughout the province goes into a repository for other regions to access. “It really enables that acceleration of replication,” said Brossart, “so we don’t reinvent the wheel or do the same thing without looking at what has been done before. It behooves us to think and act as one and to respond to this data, so the transparency is vital.”

About Better

The passion targeted to quality care for our patients demonstrated during this RPIW will lead to great results.

Kevin Kozan, patient, Regina Qu'Appelle

I was excited to be part of a much needed project. It was great to see Emergency Department physician engagement. This will be a great improvement for patient care!

Shona Lafreniere Health Records Staff, Regina Qu'Appelle

Technology is the way of the future in medicine and I think this would help everybody – physicians as well as patients!

Dr. Rossouw, Physician, Regina Qu'Appelle

Ordering supplies is logical and simplified…. (This project) will prevent an abundance of supplies that are not used, (resulting in) cost savings.

Shawn Duddridge , RN, Prairie North

This will save us a lot of time spent searching for equipment so that we can focus more on patient care.

Amanda Dela Cruz , LPN, Regina Qu'Appelle

The addition of a mobile stock/linen cart for the CCA’s with adequate stock greatly reduces lost time and steps. Go Team! By adding this time back to their day it can be used for prompt documentation and quality interactions with Residents.

Seccora Mazur, CCA, Cypress

Looking forward to saving steps and freeing up some time for Resident interaction. Good to be able to document interactions

Connie Redekop, CCA, Cypress

With now having questions to ask, there can be more one on one interactions. With the introduction of the white boards in the room, I can see what is going on as a family member and also see what they need.

Cathy Nault, patient, Cypress

I was encouraged by the electronic concept of providing documentation in the Emergency Department. As a patient advisor, it was a positive experience to work with actual patients to receive patient input and opinions into this process.

Bev Greenfield, patient, Regina Qu'Appelle

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